The Insured Person is responsible for sending a request for reimbursement to the Company, on a form provided by or satisfactory to the Company.
Claim Forms. It is not necessary to include a claim form with the proof of loss. However, the proof must include all of the following information:
Insured Person's name and address. Insured Person's identification number.
The name and address of the provider of the service(s).
A diagnosis from the Dental Provider including a complete dental chart showing extractions, fillings or other dental services rendered before the charge was incurred for the claim.
Radiographs, lab or hospital reports. Casts, molds or study models.
Itemized bill which includes the CPT or ADA codes or description of each charge. The date the dental disease began.
A statement indicating that the Insured Person is or is not enrolled for coverage under any other health or dental insurance plan or program. If enrolled for other coverage the Insured Person must include the name of the other carrier(s).
To file a claim, submit the above information to the Company at the following address: UnitedHealthcare Dental
Attn: Claims Unit P.O. Box 30567
Salt Lake City, UT 84130-0567
If the Insured Person would like to use a claim form, the Insured Person can request one be mailed by calling Customer Service at 1-877-816-3596. This number is also listed on the Insured’s Dental ID Card. If the Insured does not receive the claim form within 15 calendar days of the request, the proof of loss may be submitted with the information stated above.
Section 5: Defined Terms for Pediatric Dental Services
The following definitions are in addition to those listed in PART III, DEFINITIONS of the policy:
Covered Dental Service – a Dental Service or Dental Procedure for which benefits are provided under this endorsement.
Dental Emergency - a dental condition or symptom resulting from dental disease which arises suddenly and, in the judgment of a reasonable person, requires immediate care and treatment, and such treatment is sought or received within 24 hours of onset.
Dental Provider - any dentist or dental practitioner who is duly licensed and qualified under the law of jurisdiction in which treatment is received to render Dental Services, perform dental surgery or administer anesthetics for dental surgery.
Dental Service or Dental Procedures - dental care or treatment provided by a Dental Provider to the Insured Person while the policy is in effect, provided such care or treatment is recognized by the Company as a generally accepted form of care or treatment according to prevailing standards of dental practice.
Dental Services Deductible - the amount the Insured Person must pay for Covered Dental Services in a Policy Year before the Company will begin paying for Network or Non-Network benefits in that Policy Year.
Eligible Dental Expenses - Eligible Dental Expenses for Covered Dental Services, incurred while the policy is in effect, are determined as stated below:
For Network Benefits, when Covered Dental Services are received from Network Dental Providers, Eligible Dental Expenses are the Company's contracted fee(s) for Covered Dental Services with that provider.
For Non-Network Benefits, when Covered Dental Services are received from Non-Network Dental Providers, Eligible Dental Expenses are the Usual and Customary Fees, as defined below.
Experimental, Investigational, or Unproven Service - medical, dental, surgical, diagnostic, or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that, at the time the Company makes a determination regarding coverage in a particular case, is determined to be:
Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use; or
Subject to review and approval by any institutional review board for the proposed use; or
The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2, or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight; or
Not determined through prevailing peer-reviewed professional literature to be safe and effective for treating or diagnosing the condition or Sickness for which its use is proposed.
Foreign Services - services provided outside the U.S. and U.S. Territories
Necessary - Dental Services and supplies under this endorsement which are determined by the Company through case-by-case assessments of care based on accepted dental practices to be appropriate and are all of the following:
Necessary to meet the basic dental needs of the Insured Person.
Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the Dental Service.
Consistent in type, frequency and duration of treatment with scientifically based guidelines of national clinical, research, or health care coverage organizations or governmental agencies that are accepted by the Company.
Consistent with the diagnosis of the condition.
Required for reasons other than the convenience of the Insured Person or his or her Dental Provider. Demonstrated through prevailing peer-reviewed dental literature to be either:
Safe and effective for treating or diagnosing the condition or sickness for which their use is proposed; or
Safe with promising efficacy
For treating a life threatening dental disease or condition. Provided in a clinically controlled research setting.
Using a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health.
(For the purpose of this definition, the term life threatening is used to describe dental diseases or sicknesses or conditions, which are more likely than not to cause death within one year of the date of the request for treatment.)
The fact that a Dental Provider has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular dental disease does not mean that it is a Necessary Covered Dental Service as defined in this endorsement. The definition of Necessary used in this endorsement relates only to benefits under this endorsement and differs from the way in which a Dental Provider engaged in the practice of dentistry may define necessary.
Network - a group of Dental Providers who are subject to a participation agreement in effect with the Company, directly or through another entity, to provide Dental Services to Insured Persons. The participation status of providers will change from time to time.
Network Benefits - benefits available for Covered Dental Services when provided by a Dental Provider who is a Network Dentist.
Non-Network Benefits - benefits available for Covered Dental Services obtained from Non-Network Dentists.
Usual and Customary Fee - Usual and Customary Fees are calculated by the Company based on available data resources of competitive fees in that geographic area.
Usual and Customary Fees must not exceed the fees that the provider would charge any similarly situated payor for the same services.
Usual and Customary Fees are determined solely in accordance with the Company's reimbursement policy guidelines. The Company's reimbursement policy guidelines are developed by the Company, in its discretion, following evaluation and validation of all provider billings in accordance with one or more of the following methodologies:
As indicated in the most recent edition of the Current Procedural Terminology (publication of the American Dental Association).
As reported by generally recognized professionals or publications. As utilized for Medicare.
As determined by medical or dental staff and outside medical or dental consultants. Pursuant to other appropriate source or determination that the Company accepts.
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